- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,370.89 / $1,496.49 / $2,647.96
| Professional | | $1,370.89 | $1,496.49 | $2,647.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,415.52 / $1,415.52 / $2,110.00
| Professional | | $1,415.52 | $1,415.52 | $2,110.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,146.73 / $1,536.37 / $3,080.83
| Professional | | $1,146.73 | $1,536.37 | $3,080.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.55 / $1,622.24 / $2,663.70
| Professional | | $1,257.55 | $1,622.24 | $2,663.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.91 / $1,581.53 / $2,935.31
| Professional | | $1,112.91 | $1,581.53 | $2,935.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.93 / $997.93 / $1,762.02
| Professional | | $997.93 | $997.93 | $1,762.02 |